Objectives
To ascertain the absolute number of Medicare beneficiaries surviving at least 3 years after severe sepsis and to estimate their burden of cognitive dysfunction and disability.
Design
...Retrospective cohort analysis of Medicare data.
Setting
All short‐stay inpatient hospitals in the United States, 1996 to 2008.
Participants
Individuals aged 65 and older.
Measurements
Severe sepsis was detected using a standard administrative definition. Case‐fatality, prevalence, and incidence rates were calculated.
Results
Six hundred thirty‐seven thousand eight hundred sixty‐seven Medicare beneficiaries were alive at the end of 2008 who had survived severe sepsis 3 or more years earlier. An estimated 476,862 (95% confidence interval (CI) = 455,026–498,698) had functional disability, with 106,311 (95% CI = 79,692–133,930) survivors having moderate to severe cognitive impairment. The annual number of new 3‐year survivors after severe sepsis rose 119% during 1998 to 2008. The increase in survivorship resulted from more new diagnoses of severe sepsis rather than a change in case‐fatality rates; severe sepsis rates rose from 13.0 per 1,000 Medicare beneficiary‐years to 25.8 (P < .001), whereas 3‐year case fatality rates changed much less, from 73.5% to 71.3% (P < .001) for the same cohort. Increasing rates of organ dysfunction in hospitalized individuals drove the increase in severe sepsis incidence, with an additional small contribution from population aging.
Conclusions
Sepsis survivorship, which has substantial long‐term morbidity, is a common and rapidly growing public health problem for older Americans. There has been little change in long‐term case‐fatality, despite changes in practice. Clinicians should anticipate more‐frequent sequelae of severe sepsis in their patient populations.
Summary Background During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation ...attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. Methods Between 2000 and 2008, we identified 64 339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. Findings 31 198 of 64 339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6–21) compared with 20 min (14–30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min IQR 15–17), those at hospitals in the quartile with the longest attempts (25 min 25–28) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06–1·18; p<0·0001) and survival to discharge (1·12, 1·02–1·23; 0·021). Interpretation Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. Funding American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.
To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.
We used the Council of Medical Specialty Societies principles for the ...development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
Failure to reliably diagnose ARDS may be a major driver of negative clinical trials and underrecognition and treatment in clinical practice. We sought to examine the interobserver reliability of the ...Berlin ARDS definition and examine strategies for improving the reliability of ARDS diagnosis.
Two hundred five patients with hypoxic respiratory failure from four ICUs were reviewed independently by three clinicians, who evaluated whether patients had ARDS, the diagnostic confidence of the reviewers, whether patients met individual ARDS criteria, and the time when criteria were met.
Interobserver reliability of an ARDS diagnosis was “moderate” (kappa = 0.50; 95% CI, 0.40-0.59). Sixty-seven percent of diagnostic disagreements between clinicians reviewing the same patient was explained by differences in how chest imaging studies were interpreted, with other ARDS criteria contributing less (identification of ARDS risk factor, 15%; cardiac edema/volume overload exclusion, 7%). Combining the independent reviews of three clinicians can increase reliability to “substantial” (kappa = 0.75; 95% CI, 0.68-0.80). When a clinician diagnosed ARDS with “high confidence,” all other clinicians agreed with the diagnosis in 72% of reviews. There was close agreement between clinicians about the time when a patient met all ARDS criteria if ARDS developed within the first 48 hours of hospitalization (median difference, 5 hours).
The reliability of the Berlin ARDS definition is moderate, driven primarily by differences in chest imaging interpretation. Combining independent reviews by multiple clinicians or improving methods to identify bilateral infiltrates on chest imaging are important strategies for improving the reliability of ARDS diagnosis.
The extent to which geographic variability in ICU admission across the United States is driven by patients with lower risk of death is unknown.
To determine whether patients at low to moderate risk ...of death contribute to geographic variation in ICU admission.
Retrospective cohort of hospitalizations among Medicare beneficiaries (age > 64 years) admitted for ten common medical and surgical diagnoses (2004 to 2009). We examined population-adjusted rates of ICU admission per 100 hospitalizations in 304 health referral regions (HRR), and estimated the relative risk of ICU admission across strata of regional ICU and risk of death, adjusted for patient and regional characteristics.
ICU admission rates varied nearly two-fold across HRR quartiles (quartile 1 to 4: 13.6, 17.3, 20.0, and 25.2 per 100 hospitalizations, respectively). Observed mortality for patients in regions (quartile 4) with the greatest ICU use was 17% compared to 21% in regions with lowest ICU use (quartile 1) (p<0.001). After adjusting for patient and regional characteristics, including regional differences in ICU, skilled nursing, and long-term acute care bed capacity, individuals' risk of death modified the relationship between regional ICU use and an individual's risk of ICU admission (p for interaction<0.001). Region was least important in predicting ICU admission among patients with high (quartile 4) risk of death (RR 1.27, 95% CI 1.22-1.31, for high versus low ICU use regions), and most important for patients with moderate (quartile 2; RR 1.63, 95% CI 1.53-1.72, quartile 3; RR 1.56 95% CI 1.47-1.65) and low (quartile 1) risk of death (RR 1.50, 95% CI 1.41-1.59).
There is wide variation in in ICU use by geography, independent of ICU beds and physician supply, for patients with low and moderate risks of death.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
National trends in tracheostomy for mechanical ventilation (MV) patients are not well characterized.
To investigate trends in tracheostomy use, timing, and outcomes in the United States.
We ...calculated estimates of tracheostomy use and outcomes from the National Inpatient Sample from 1993 to 2012. We used hierarchical models to determine factors associated with tracheostomy use among MV patients.
We identified 1,352,432 adults who received tracheostomy from 1993 to 2012 (9.1% of MV patients). Tracheostomy was more common in surgical patients, men, and racial/ethnic minorities. Age-adjusted incidence of tracheostomy increased by 106%, rising disproportionately to MV use. Among MV patients, tracheostomy rose from 6.9% in 1993 to 9.8% in 2008, and then it declined to 8.7% in 2012 (P < 0.0001). Increases in tracheostomy use were driven by surgical patients (9.5% in 1993; 15.0% in 2012; P < 0.0001), with little change among nonsurgical patients (5.8% in 1993; 5.9% in 2012; P < 0.0001). Over time, tracheostomies were performed earlier (median, 11 d in 1998; 10 d in 2012; P < 0.0001), whereas hospital length of stay declined (median, 39 d in 1993; 26 d in 2012; P < 0.0001), discharges to long-term facilities increased (40.1% vs. 71.9%; P < 0.0001), and hospital mortality declined (38.1% vs. 14.7%; P < 0.0001).
Over the past two decades, tracheostomy use rose substantially in the United States until 2008, when use began to decline. The observed dramatic increase in discharge of tracheostomy patients to long-term care facilities may have significant implications for clinical care, healthcare costs, policy, and research. Future studies should include long-term facilities when analyzing outcomes of tracheostomy.
Purpose
Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to ...understand factors that influence how intensive care unit (ICU) admission decisions are made.
Methods
A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations.
Results
A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it.
Conclusion
Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.
OBJECTIVE:Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern ...variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.
DESIGN:In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomypneumonia/sepsis and trauma. “Early tracheostomy” was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.
SETTING:2012 National Inpatient Sample.
PATIENTS:A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01–1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98–1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9–81.9%) compared with pneumonia/sepsis (14.9–38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.
CONCLUSION:Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.
OBJECTIVES:Changes in population demographics and comorbid illness prevalence, improvements in medical care, and shifts in care delivery may be driving changes in the composition of patients admitted ...to the ICU. We sought to describe the changing demographics, diagnoses, and outcomes of patients admitted to critical care units in the U.S. hospitals.
DESIGN:Retrospective cohort study.
SETTING:U.S. hospitals.
PATIENTS:There were 27.8 million elderly (age, > 64 yr) fee-for-service Medicare beneficiaries hospitalized with an intensive care or coronary care room and board charge from 1996 to 2010.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:We aggregated primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnosis codes into diagnoses and disease categories. We examined trends in demographics, primary diagnosis, and outcomes among patients with critical care stays. Between 1996 and 2010, we found significant declines in patients with a primary diagnosis of cardiovascular disease, including coronary artery disease (26.6 to 12.6% of admissions) and congestive heart failure (8.5 to 5.4% of admissions). Patients with infectious diseases increased from 8.8% to 17.2% of admissions, and explicitly labeled sepsis moved from the 11th-ranked diagnosis in 1996 to the top-ranked primary discharge diagnosis in 2010. Crude in-hospital mortality rose (11.3 to 12.0%), whereas discharge destinations among survivors shifted, with an increase in discharges to hospice and postacute care facilities.
CONCLUSIONS:Primary diagnoses of patients admitted to critical care units have substantially changed over 15 years. Funding agencies, physician accreditation groups, and quality improvement initiatives should ensure that their efforts account for the shifting epidemiology of critical illness.
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